- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $53.98 / $71.46 / $121.52
| Facility | 26 | $53.98 | $71.46 | $121.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.02 / $221.11 / $381.69
| Professional | | $186.02 | $221.11 | $381.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.72 / $286.79 / $461.67
| Professional | | $208.72 | $286.79 | $461.67 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $63.01 / $63.01 / $63.01
| Facility | 26 | $63.01 | $63.01 | $63.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.53 / $351.21 / $552.12
| Professional | | $250.53 | $351.21 | $552.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.15 / $290.18 / $498.10
| Professional | | $210.15 | $290.18 | $498.10 |